12339-C Advisory Committee on Tax Exempt and Government Entities

Department of the Treasury - Internal Revenue Service

Form 12339-C
(Rev. February 2014)

OMB Number
1545-1791

Advisory Committee on Tax Exempt and
Government Entities - Membership Application

Complete this application and return it to the address below.
Internal Revenue Service
Tax Exempt and Government Entities
SE:T:CL/NCA 676
1111 Constitution Avenue, NW
Washington DC 20224
You may also FAX your application to: (877) 801-7395.

PART I – Applicant Information (Some of the information requested in Part I is required to perform an FBI background check)
Name

Maiden name or other name(s) used

Date(s) names were used

Home street address

Home telephone number

City

State

Date of birth (mm-dd-yyyy)

City of birth

ZIP Code

State of birth

Business name

Business address

Job title

City

State

Business telephone number

Business FAX number

ZIP Code

Email address

Which Tax Exempt and Government Entities customer segment vacancy are you applying for?
Employee Plans
Exempt Organizations
Federal, State and Local Governments
Indian Tribal Governments

Tax-Exempt Bonds

PART II – Applicant must complete and submit Form 13775, Tax Check Waiver, with this form
PART III – Desired Skills and Qualifications
Submit a short (one or two page) statement, including recent examples, addressing your specific skills and qualifications as they relate
to the following:
● Applying tax law knowledge related to employee plans, exempt organizations, government entities, or tax exempt bonds.
● Experience in business management and improvement.
● Experience establishing successful strategic partnerships.
● Ability to examine issues from a "macro" viewpoint, and effectively communicate.
● Your views and recommendations about these issues.

PART IV – Applicant Resume
Attach a copy of your resume, including prior Treasury and/or IRS employment. State position(s), title(s), and dates of employment. In
addition, list professional credentials, membership in professional organizations, and local liaison activities with IRS, if applicable.
Catalog Number 58763Y

www.irs.gov

Form 12339-C (Rev. 2-2015)

PART V – Other IRS Councils/Committees
Have you ever been a member of the Internal Revenue Service Advisory Council (formerly known as Commissioner's Advisory Group),
Art Advisory Panel, Electronic Tax Administration Advisory Committee, Tax Exempt Advisory Committee or Information Reporting
Program Advisory Committee? If so, please include name of the councils/committees and dates of membership.
Councils/Committee name

Dates of Membership

PART VI – Applicant Acknowledgement
I certify that to the best of my knowledge and belief, all of my statements are true, correct, complete, and made in good faith.
Applicant signature

Date signed

Privacy Act Statement
The Privacy Act of 1974 requires that when we ask you for information about yourself, we state our legal right to do so, tell you why we are asking for it,
and how it will be used. We must also tell you what could happen if we do not receive it, and whether your response is voluntary, required to obtain a
benefit, or mandatory. Our legal right to ask for the information is Public Law 92-463 and Executive Order (E.O.) 9397. We are asking for the information
in order to perform Federal income tax, FBI, and practitioner checks as required of all members and applicants to the Advisory Council/Committee.
Supplying the information is voluntary and not directly required by law, but facilitates the processing of your application for membership in the IRS
Advisory Council/Committee. Requesting your social security number, which is solicited under authority of E.O. 9397, is also voluntary and no right,
benefit, or privilege provided by law will be denied as a result of refusal to disclose it. However, not providing all or any part of the information may limit
consideration of your application.

Paperwork Reduction Act Notice
Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required to
give us the information. We need it to ensure that you are complying with these laws and to allow us to figure and collect the right amount of tax. You are
not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control
number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are confidential, as required by section 6103.The time needed to complete and
file this form will vary depending on individual circumstances. The estimated average time is shown below. The estimated burden for all other taxpayers
who file this form is approved under OMB control number 1545-1791.
Preparing, copying, assembling, and sending the form to the IRS …………………….. 10 mins.
If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from
you. You can write to: Internal Revenue Service, Tax Exempt and Government Entities, SE:T:CL/NCA 676, 1111 Constitution Avenue, NW, Washington
DC 20224. Do not send the form to this address. Instead, see the return address on the form.
Catalog Number 58763Y

www.irs.gov

Form 12339-C (Rev. 2-2015)